Assessment

Intact: Left Right

Impaired: Left Right

Hearing device present: Left Right

Interior

Normal: Left Right

Redness: Left Right

Cerumen present: Left Right

Swollen: Left Right

Eyes

Sclera

Normal/clear: Left Right

Jaundice: Left Right

Redness: Left Right

Swelling: Left Right

Movement

Symmetrical: Left Right

Intact: Left Right

Nystagmus: Left Right

Lid lag: Left Right

Asymmetrical corneal reflections: Left Right

Convergence

Average: Left Right

Poor: Left Right

Nose

Character

Symmetrical:

Asymmetrical:

Deformity:

Obstruction

Absent:

Present left:

Present right:

Septum

Intact:

Perforated:

Deviated:

Abnormalities

Ulcers present:

Polyps present:

Blood present:

Recent trauma:

Mouth/Throat

Teeth

Present:

Absent:

Tooth Decay:

Cavity(ies):

Implant(s):

Cap(s):

Bridge(s):

Dentures:

Swelling:

Oral Mucosa

Normal:

Ulcers:

Pink:

White:

Pale:

Dusky:

Swelling:

Moist:

Dry:

Pharynx

Normal:

Exudate:

Swelling:

Ulceration:

Tonsillar enlargement:

Pain:

Lymph Nodes

Non-tender:

Tender:

Shotty:

Location: Left Right